What constitutes a workers’ compensation claim?

Insureon Staff.
By Insureon Staff
May 15, 2014
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To access workers' comp benefits, the employee and the employer must follow certain steps to ensure the injury is compensable.
A work injury claim form and stethoscope.

When an employee is injured on the job or develops an occupational illness, there are two options: sue the employer or file a workers’ compensation claim. Filing a claim means the employee can receive medical coverage, wage replacement, and other benefits. To access these benefits, both the employee and employer must follow certain steps to ensure the injury is compensable.

The process of filing a claim can be a bit complex because there are several parties involved: the employee, the employer, the insurance company, the doctor, and the state’s workers’ compensation board. Certain facts about the employee and the nature of the injury must be true and there's often a deadline for filing, too.

When to file a workers’ comp claim

Your employee is eligible for workers’ comp benefits so long as the following statements are true:

  • The injured worker is an employee of your small business (not an independent contractor)
  • The employer has workers’ comp insurance
  • The employee was hurt as a result of job-related duties

Most injuries that occur on the job or fall within the scope of employment can be covered by workers’ comp. This includes occupational accidents, diseases, trauma injuries, or illness caused by exposure to work activities or chemicals.

As soon as an employee suffers a covered occupational injury, time is of the essence. The employee has a limited number of days to report the incident and collect benefits.

Typically, an occupational injury should be reported to the employer as soon as it occurs. If there is a delay in filing, the insurance provider could potentially deny the employee compensation benefits. The delay may also give your carrier the impression that the claim isn’t legitimate.

Workers’ comp generally doesn’t cover:

  • Stress or other psychiatric injuries
  • Self-inflicted injuries
  • Injuries caused by fighting or horseplay
  • Injuries that happen on the commute to or from work
  • Injuries incurred while committing a crime, while under the influence of drugs or alcohol, or while violating company policies

For cumulative work injuries or illnesses, the area gets a little grayer. For example, say a technical writer develops carpal tunnel syndrome over time. Generally, the clock starts ticking on this claim when:

  • The writer took time off work because of the injury
  • The writer knew that the injury was caused by work

How to file a workers’ comp claim

To initiate the claims process, an employee must:

  • Notify the employer about the work injury or illness (including the date, time, type of injury, and how the injury occurred)
  • File a formal workers’ comp claim

From there, the insurance company will choose a doctor to conduct an independent medical examination (IME). The doctor will report the results to the insurance company, which uses the report to create its compensation offer.

It’s worth noting that the workers’ comp claims process differs slightly from state to state. To learn about the rules in your state, refer to its workers’ compensation board.

Workers’ compensation statue of limitations

Different states have different statues of limitations for filing workers' comp claims. That means depending on where you live, your employees will have a specific deadline for filing a claim (which may vary based on the type of injury). For example, in Maryland, the statute of limitations for filing a workers’ comp claim is two years from the date of the injury.

Another deadline is the amount of time an employee has to notify the employer about the injury. In most cases, the employer must be notified within 30 to 45 days of the injury. For example, in Missouri, employees who fail to notify the employer within 30 days of the injury can jeopardize their ability to receive workers’ compensation benefits.

The notification can be a formal letter or email detailing the work injury, or it can be informal, such as an employee mentioning wrist pain caused from typing all day. To err on the side of caution, always ask an injured employee to submit a written notification of the injury detailing the nature of the ailment and when, how, and where it occurred.

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